Digital Mental Health

Note to readers: This is a long-ish read (closer to 15 rather than 5 minutes)

As someone who studies mental health, I rarely stop to ask myself about its definition. Yet, definition is increasingly at the front of my mind when I think about the field of digital mental health.

I know all the modern textbook definitions, but find myself drawn to a definition that was put forward over 60 years ago by Erich Fromm in his book The Sane Society. One of the founders of what would come to be known as Humanistic Psychology, Fromm wrote “Mental health is characterized by the ability to love and to create, ….by a sense of identity based on one’s experience of self as the subject and agent of one’s powers, [and] by the grasp of reality inside and outside of ourselves, that is, by the development of objectivity and reason.”

I love this definition because of its focus on what seems to me to really make us human: loving, creating, and having a desire for knowledge. The field of digital mental health is moving forward at a breakneck speed without considering the basic question of how it might promote – or disrupt – these building blocks of a sane and humane society and of our individual mental health within it. Moreover, it is developing in a world of obsessive social media use, mobile phone addiction, fake news, digital data insecurity, internet trolls, and the Uber-fication of human service industries, all of which serve a single, primary objective of absolute efficiency – getting what we want as quickly and easily as possible at all times.

Here I highlight key challenges we face in creating humane and effective health technology in a toxic digital ecosystem, lay out a four-point road map, and, as a case study, describe the development of a micro-intervention app for stress- and anxiety-reduction I developed called Personal Zen.

The Promise of Digital Mental Health

The potential payoffs of digital mental health are of crucial importance now. We are facing an ever-growing mental health epidemic in the US and around the world. Over half of us will be diagnosed with a mental health disorder in our lifetime. And our kids are struggling. Approximately one in every 4–5 youth in the U.S. meets criteria for a mental disorder with severe impairment, and the vast majority of mental health disorders in adults first emerge in childhood and adolescence.

The particular promise of computerized and mobile interventions are that they can, if done properly, radically increase the availability and accessibility of empirically-validated treatments, while reducing cost and stigma.

The Toxic Digital Ecosystem and Techlash

We’re used to believing, with true tech-enthusiasm, that if only we can “disrupt” current healthcare delivery systems, we can solve all our problems. But we now realize with growing certainty that what the digital ecosystem truly excels at is making money for technology companies and pushing us towards ever-greater efficiency. It does this so well because it is precisely and purposefully designed to grab our attention, addict us, and keep us glued to our screens: This is the basis of the attention and surveillance economies. The result of this design focus is that digital technology exhausts us, distracts us, and detracts from our ability to do other things.

Awareness of this has caused the pendulum to swing the other way, and we’ve entered an era of “tech-lash” with growing outcry about mobile phone addiction, negative effects of social media on youth mental health, data security, the spread of fake news, unethical business practices, and the list goes on. We are angry at Silicon Valley because these powerful companies created ubiquitous products and put profit so far above our well-being, that it’s unclear what to do about it.

Such is the degree of techlash now that even scientists are seeing causation in correlation before solid facts are established. In 2017, researchers, usually a circumspect bunch, went so far as to suggest in the popular media that smartphones have psychologically destroyed a generation of youth, citing among other findings that during the period following the birth of the iPhone about 10 years ago, we have seen a doubling of suicide rates and increases in depression and anxiety across vast segments of society.

In its annual survey of students, the American College Health Association found a significant increase — to 62 percent in 2016 from 50 percent in 2011 — of undergraduates reporting “overwhelming anxiety” in the previous year. Surveys that look at experiences related to anxiety are also telling. In 1985, the Higher Education Research Institute at U.C.L.A. began asking incoming college freshmen if they “felt overwhelmed by all I had to do” during the previous year. In 1985, 18 percent said they did. By 2010, that number had increased to 29 percent. Last year, it surged to 41 percent. These are alarming statistics, but is this enough evidence that smartphones are causing these problems?

I believe not. I have come to doubt conventional wisdom that smartphones or social media are a unique cause of anxiety, depression, or suicide; instead, I see them as a factor among many. By primarily “blaming the machines” we obscure the impact of other factors of equal or perhaps greater importance, and lose opportunities to deeply examine a range of factors and how they might work together with digital technology to contribute to the suffering of youth and adults.

As the evidence comes in, how do we work in an arguably toxic digital ecosystem to ensure that – for adults and children – health technology heals rather than harms?

A Four-Point Road Map for Humane Digital Mental Health Technology

For health technology to be truly humane, it must meet these four criteria:

Prioritize development of micro-interventions. An irony of digital mental health is that the well-honed attention economy techniques that keep people glued to screens will work against mental health promotion. Therefore, focus should be on creating micro-interventions that require as little screen time as possible. Micro-interventions are brief and frequent, easily fitting into a person’s routine at home or on-the-go. They are part of the broader spectrum of care, with low-intensity preventative or “gateway” treatments at one end and intensive stand-alone treatments on the other end. Development efforts in health technology should be focused now on the low-intensity end of the spectrum. Later, once a strong evidence base is built, resources should then be devoted across the spectrum to develop more intensive, resource-heavy and stand-alone treatments. This strategy is largely reversed in digital healthcare right now. Many companies are trying to digitize gold-standard treatments like cognitive behavioral therapy (CBT), which remains time-consuming and expensive. Moreover, it remains unclear whether CBT is effective in digital or telemedicine format. Making poorly-validated treatments widely available does not solve the mental healthcare crisis.

Maximize high accessibility. Along with the development of brief, micro-interventions, digital mental health must be qualitatively more accessible than current treatment delivery systems – affordable, easy to access, used on-the-go, and engaging. Current psychological treatments are often time-consuming and expensive. Of the over 160 million Americans who will have mental health problems in their lifetime, 50% of us don’t seek any treatment with 44% of these untreated patients citing price as a barrier. Basic access is also highly limited – over 83 million Americans live in federally-designated Mental Health Professional Shortage Areas.

Reduce stigma. The stigma of mental illness represents a significant barrier to mental healthcare access. Of the tens of millions of untreated Americans struggling with mental health, 10% cite the stigma of mental illness – and fearing others will find out – as a primary barrier. A benefit of digital and mobile mental health interventions is that when we access mental wellness tools on our devices, they become part of our enjoyable and daily digital lives, increasing the possibility of normalization. Developers can also aim to create interventions that are fun and engaging, rather than having the clinical and medical feel that might turn people away from seeking help in the first place.

Make adaptive and personalized. The promise of machine learning, artificial intelligence, and big data for solving health problems are immense. The most sophisticated techniques for data generation and gathering have been used in the worlds of advertising and politics, but these emerging techniques have already made waves in terms of medical diagnosis and risk assessment. In mental health, the ability to dynamically evaluate a treatment target and personalize interventions accordingly are the future of mental healthcare. At this stage, few research-based mental health tools have built-in adaptive methods. This is among the most important areas in which academia and industry must come together, one that holds perhaps the greatest promise for true personalization of treatment.

Summary: Development of humane and effective digital mental health technology must optimize the accessibility and mobility of digital technology, shift focus towards brief, flexible, and personalized interventions, and reduce screen time in order to step off the attention economy treadmill. This approach minimizes the harmful aspects of the digital ecosystem while capitalizing on its nimble, accessible, and stigma-reducing aspects.

Finding Personal Zen

I had the idea of humane health technology as a guiding principle when I created the app Personal Zen. Personal Zen is a stress- and anxiety-reduction exercise. The app embeds scientifically-based attention training techniques into an engaging and appealing format. Its scientific “active ingredient” is something called attention bias modification.

Attention biases are rigid and selective ways of paying attention to information in the world. Decades of research tell us that people who tend to be anxious or stressed detect negative information more quickly, and pay attention to it longer and intensely than people who are relatively less anxious and stressed.

This preference to pay attention to the negative is called the threat bias. And here’s the kicker: The threat bias piggybacks on one of the triumphs of evolution – the ability to quickly and automatically notice danger, which in turn triggers us to fight or take flight to deal with the danger. But the threat bias highjacks and skews this evolutionary advantage. It acts as an unconscious information filter, an imbalance in what we pay attention to that makes us actually prefer and prioritize threat and negativity at the expense of the positive. When the threat bias becomes a rigid habit of looking at the world, it puts our fight/flight response on a hair trigger, and sky-rockets our feelings of stress and anxiety. We see monsters in the closet even when they’re not there.

Personal Zen is designed to retrain our attention to disengage from the negative in flexible ways so that we can better benefit from positive information all around us. This creates a stronger attention filter favoring the positive. As a micro-intervention, it was designed to be used briefly and on-the-go, so it can fit into anyone’s daily routine.

Findings suggest that this technique loosens the vicious cycle of stress and anxiety, immediately reducing distress as well as laying the groundwork for positive change. We’ve published three clinical trials of Personal Zen showing that even with short-term use, Personal Zen can reduce stress and anxiety. We’ve recently focused on the potential benefits of Personal Zen for a group of people in particular need of easy-to-access stress-reduction tools that can fit into their busy lives – pregnant women – and found that using Personal Zen for about 30 minutes a week for a month reduced the stress hormone cortisol. While much more work needs to be done, I believe that with this approach, we’re on the right track.

The Future is Now

The field of digital mental health is skyrocketing at a time when there are compelling arguments to reduce screen time. Humane digital mental healthcare must navigate this contradiction while taking the best that digital technology has to offer to actively promote the essence of mental health in us all: the ability to love and create, to have an empowered sense of self, and to embrace objectivity and reason. It’s up to us all, researchers, developers, and healthcare professionals, to get this right.

This post is from 5 years ago, July, 2013. I believe we’re all still thinking about and struggling with these same issues today!

Games that are not games. There is a serious barrier to the effective gamification of mental health. This barrier is that the games we psychologists and health professionals are coming up with are not fun. In fact, they are totally uncool, border on the condescending, and wouldn’t motivate anyone to play for more than 30 seconds. This is the case even though the bar is set quite low because these “games” address things that people really want, like boosting our intelligence and memory, reducing depression and stress, quitting smoking, … fill in the blank. I’ve been fascinated with this disconnect between Psychology’s view and real-world acceptability. This disconnect is plaguing other fields as well, such as in the development of “serious games” for education. In this larger context, I’ve been working on the development of an app that takes a scientifically proven approach to reducing stress and anxiety, and embeds the “active ingredient” of this intervention into a game that is fun – fun enough, we hope, for someone to want to play for much more than 30 seconds.

Fun versus health goals. In the midst of this ongoing development process, I had the pleasure of speaking with Nick Fortugno, co-founder of the game design company Playmatics. In addition to creating really fun games, like Diner Dash, he has created games to promote positive social change and is one of the visionary and forward-thinking advocates for the idea that serious games can and should be fun. So, he has a deep understanding of the barriers facing the gamification of mental health. As we were talking about these barriers, Nick said something that really got me thinking. He said, when we design games for education or health, we have to remember that “the game doesn’t care” about whether we’re making progress towards our goal. In other words, a game isn’t fun because it meets some criterion that we, the developers, have for success – like boosting our ability to remember, reducing symptoms of anxiety, or losing 5 pounds. A game is fun because it creates an aesthetic experience and facilitates game play that we want to come back to again and again. Therefore, I would argue that a “serious” goal embedded in a truly fun game is reached as a by-product of the fun.

The need for backward engineering. I think I am accurate in saying that very few people, myself included, who are trying to create serious games for wellness think like this – i.e., like a game designer – about the process of gamification. From what I can tell, game designers think very deeply about the experience they want the game to promote, and then they work through the pragmatics of the game play that will facilitate this experience. This backward engineering from the point of view of the aesthetic/experiential goal to the pragmatics of the game is the opposite of what psychologists do when they think about gamification. Instead, we have parallel streams of development in which (a) we know that our “game” (read scientific protocol) is truly boring, and (b) we have to somehow decrease the snore factor. We think: “Hm, here is my very rigid experimental protocol/computerized intervention. I must overlay this protocol with some cute little animated guys, perhaps with a fun back-story (wizards? aliens?) and then make sure users get points when they conform to the requirements of the protocol.” Sounds thrilling, huh? So fun? Exactly the recipe for the next Dots? Right…. So, we have a lot to learn from game designers, and I believe that crucial to the future of the endeavor of gamifying mental health is partnering with people who know how to create fun and understand the process of game design.

Pocket rituals. What would it be like if we created mental wellness tools, or even interventions for serious mental health problems, that were truly fun and that could become part of our array of habits and strategies for feeling better, reducing symptoms, performing more efficiently, or dealing with stress? These games, if “snackable” would become our pocket rituals, our chill pills. We could take out our device for 5, 10, or 15 minutes and be empowered to bring about a targeted, appreciable positive impact. The barriers to use should be minimal, the experience intrinsically rewarding – that is, it feels good to play – as well as reinforcing because it helps us meet our health goals. I think many psychologists feel that this approach is not easily conducive to a rigorous scientific approach. But if we fail to find a way to do this – good science and giving people tools they want to use – then the whole endeavor is dead in the water.

Social media and digital technology must have an impact on our emotional lives because our social lives—whether analog or digital—always do. In my recent article for Psychology Today, I write about why we must move beyond “Is there an impact?” to “How, Why, and under What conditions is there an impact?”. Read the full article here.

With the election less than two weeks away, we’re revisiting a previous post on “Politics and the Culture of Fear: Is There a Place for Digital Disruption?”:

It feels as if we can’t escape the culture of fear and extremism that is pervading politics. Political discourse is more vitriolic than ever after San Bernardino and Paris, and during the months of partisan name-calling and ugly mud-slinging among candidates for the U.S. Presidential Race. And clearly, there are no easy solutions to unraveling this vicious cycle.

During the Christmas holiday, I had an experience that perfectly illustrated this to me. My family and I were at a friend’s house for a holiday event, and I overheard her guests talking as I walked through the kitchen. I heard, “The more he says, the more I like him.” Then, “He says the things we all think but are afraid to say.” I started to get that sick feeling in the pit of my stomach, hoping they weren’t talking about Donald Trump. Then I heard, “The only problem with building a wall between Mexico and the U.S. is that it will have to be so big that it’s impractical and expensive.” I tried to talk myself off the ledge, saying to myself, “Don’t open your mouth, just keep walking, don’t say anything, it won’t help or change anyone’s mind…..” But then as I was about to turn the corner, safely avoiding a conversation that would surely have turned ugly, I heard, “Of course we should ban Muslims from entering the country. Look what they did in Paris.” So, I turned sharply on my heel and unwisely marched over to the little group sitting around the kitchen table.

“Excuse me,” I said, “but I couldn’t help but overhear your conversation, and I wish that you would consider the fact that excluding or persecuting people solely on the basis of their religion or ethnicity is how (voice rising) the Holocaust started.” And then, when the response to that grenade lob was dropped jaws and the explanation, “It would only be temporary,” I looked at them incredulously, probably with disgust on my face, and said, “That’s what Hitler said and” just in case they didn’t get it the first time, “that’s how the Holocaust started.” Then I abruptly left, muttering, “This was a mistake, I can’t talk about this…..”

I found this conversation terrifying – not only because the thought of Trump as President is terrifying, nor because I was disappointed in myself because I lost my cool, and created an extreme, unbridgeable divide between our viewpoints by invoking the Holocaust. No, this conversation was most terrifying because these people were not bad people. They were the type of people I appreciate: good, kind, hard-working people who love their kids and their family.

So where does that leave us?

I don’t have a solution, and indeed, my own extreme reaction during the kitchen table conversation shows that I lack objectivity and am certainly part of the problem. I do, however, as a scientist believe that we can harness what we know about our minds and brains to neutralize this vicious cycle of social and political extremism. Could digital disruption help move us along a path to such change? There might not be an app for that, but below I list three steps I believe could put us on the road towards digital disruption of the political culture of fear.

1. Frame political extremism as an emotion regulation problem. Before any digital disruption can happen, we have to make sense of the problem and have a concept of what’s going wrong. We have all had one of those kitchen table conversations I described above. In these conversations, our emotions get the better of us – fear, disgust, anger. This is a problem in how we control our emotions and how our emotions control our thoughts, decisions, and actions – something psychologists call emotion regulation. The problem is that our strong emotions rarely convince our debating partners. Instead, they solidify the views everyone already holds, causing us to cling to them even more strongly and rigidly. Common ground is lost, and the divide between perspectives seems increasingly unbridgeable.

Imagine how a version of that kitchen table conversation happens on the political world stage, sabotaging attempts at diplomacy and mutual understanding. The result is not just upset and angry people. Now the result is that our emotions directly shape political discourse, legal decisions, and policies that can affect generations to come.

Thus, a first crucial step towards disruption of the political culture of fear is to frame political discourse in terms of emotion regulation – applying what we know about what goes wrong and how to fix it on the individual and group level.

2. Use technology to promote empathy. Recent research in political psychology suggests that empathy can help heal rancorous political divides. A recently-published study showed that when political advocates fail to understand the values of those they wish to persuade, this “moral empathy gap” causes their arguments to fail. However, when political arguments are reframed in the moral terms of the other side, they are more effective. For example, when asked about their views on universal healthcare, conservatives who heard “purity arguments” (e.g., sick people are disgusting and therefore we need to reduce sickness) were friendlier towards universal healthcare, compared to when they heard “fairness arguments,” which are more consistent with liberal values.

If we can use technology to bridge the moral empathy gap, we might be able to reduce political polarization and promote better emotion regulation, more compromise, and deepened understanding. Virtual Reality (VR) might be one such technology. I previously wrote about Chris Milk’s thought-provoking TED talk on VR as the “ultimate empathy machine.” By creating a sense of presence and of real interactions with people and worlds, VR forges empathic bridges leading to greater understanding and compassion. In his work with the UN, Chris Milk uses VR to vividly portray the plight of refugees to politicians and policy makers. How does seeing and experiencing the suffering of 5-year-old children in the refugee camps influence policy making?: Almost certainly for the better.

3. Use technology to calm the fearful brain. As political ideologies become increasingly polarized, neuroscience research suggests that the differences between liberal and conservative viewpoints may extend beyond policy preferences to fundamental differences in the “fearful brain.”

In a paper I wrote in 2014 with Dave Amodio, a professor at NYU, we found that children of liberal compared to conservative parents showed a stronger “N2” brain response to mildly threatening and conflicting information. A greater N2, derived from EEG, suggests more openness to uncertainty, ambiguity, and threat. A culture of fear, in politics or otherwise, is marked by the opposite of this: inflexibility and discomfort in the face of uncertainty and ambiguity, along with resistance to change. These aspects of fear are part of the foundation upon which intolerance is built.

What if we could create computerized interventions that promote our ability to cope with uncertainty and change – perhaps by strengthening the N2 response? My research on the stress reduction app Personal Zen, as well as other research, shows that this may be possible. More research is needed, but if science-driven digital mental health continues to evolve, reducing the political culture of fear could soon be in the palm of our hand.

“Calming the Politics of Fear: Technology and the Anxious Brain” is my talk from Personal Democracy Forum 2016 (June 10, 2016), adapted here for a written format. This talk was part of a set of talks entitled “Tools We Need.” I argue that using technology in the service of health is a very sharp, double-edged sword, and that we must reclaim technology culture to serve and amplify humanity and well-being, rather than serve the digital economy. The video of the talk is available here.

Threat Bias

I became a psychologist and a researcher because I wanted to help people overcome problems like anxiety and depression. But I quickly discovered that no one likes you when you are a mental health professional. Psychologists pry into people’s minds and tell you it’s your mother’s fault. Psychiatrists prescribe you drugs with terrible side effects and that emotionally numb you. It’s no coincidence that Hannibal Lector is a psychiatrist.

And that’s when I got it. We psychologists and psychiatrists have profoundly failed people. We have failed to give people the treatments they need – and instead give people treatments that are too expensive, too time consuming, too hard to access, and perhaps most importantly, deeply stigmatizing. Largely because of us, people fear that their hearts and minds will never heal and that they will continue to feel broken inside.

I believe that digital technology can offer us some unique ways out of this mess, and provide tools for both professionals and each of us as individuals to heal problems like anxiety and depression.

But I also believe that using technology in the service of health is a very sharp, double-edged sword, with high potential costs as well as benefits.

In my research lab, we study things called cognitive biases – invisible habits of thinking and paying attention that intensify and even cause anxiety, depression, and addiction. I’ve translated this research into digital techniques that are designed to short circuit cognitive biases.

Let me explain cognitive biases by conducting a little experiment. Please fix your eyes on the screen. [[The following picture flashed up on the screen for 2 seconds]]

How many of you saw the angry face? How many didn’t? The results of our experiment?: Decades of research tell us that people who tend to be anxious or stressed detect that angry face more quickly, and pay attention to it longer and intensely than people who are relatively less anxious and stressed.

This preference to pay attention to and prioritize the negative is called the threat bias. And here’s the kicker. The threat bias piggybacks on one of the triumphs of evolution – the ability to quickly and automatically notice danger, which in turn triggers us to fight or take flight to deal with the danger.

But the threat bias highjacks and skews this evolutionary advantage. It acts as an unconscious information filter, an imbalance in what we pay attention to that makes us actually prefer and prioritize threat and negativity at the expense of the positive. When the threat bias becomes a rigid habit of looking at the world, it puts our fight/flight response on a hair trigger, and sky-rockets our feelings of stress and anxiety – We see monsters in the closet even when they’re not there.

For example, imagine you’re giving a talk, like I am now, and there is a smart audience in front of you, bright lights beaming down. If I had an amped-up threat bias, I would very quickly and intensely notice that there is this one person in the audience who is frowning, shaking his or her head, maybe falling asleep. I will fail to notice all the interested and smiling faces in the audience, and get stuck on this person. The natural result – I feel more anxious and stressed, I am on the look-out for further negative information, and I ignore positive evidence that I’m doing a good job.

In this way, the threat bias drives the vicious cycle of stress and anxiety, takes up mental bandwidth, and puts us at a disadvantage when there is no real danger to face, when the monsters in the closet are only in our mind.

Personal Zen

Now, this threat bias doesn’t sound so great. Not great at all. But I love the threat bias and other cognitive biases. That is because there is an empowering message hidden in the idea of cognitive biases. Biases are essentially habits. When we have a bad habit, we are not broken inside – to change, we just need to learn a new habit.

So I have spent a good part of my 20-year career studying how we can derail cognitive biases like the threat bias, learn new habits to heal the anxious brain, and translate these techniques into a digital format.

Over these 20 years as a researcher, I’ve done all the things that a researcher is supposed to do, and enjoyed the process: received grants, run dozens of studies, published over fifty scientific papers on everything from the emotional lives of children to the neuroscience of the anxious brain, became a full, tenured professor at the City University of New York, where I founded the Emotion Regulation Lab, The Center for Stress, Anxiety and Resilience, and the Center for Health Technology and Wellness.

But I only really began to make progress and question how my research on cognitive biases was making a difference when I was pregnant with my daughter. I was talking to my husband about how I felt stuck, and that maternity leave was going to be my chance to think outside the box and he says, “Why don’t you build an app for that?” An app, I said – that’s ridiculous. There are too many “apps for that,” ugh.

But, he got me thinking that maybe this really was a way to do things differently.

Enter attention bias modification, a technique I study in my lab and that takes the threat bias and turns it on its head. Attention bias modification sounds a little like this:

But I promise you, it’s not. Attention bias modification uses simple computerized techniques to rebalance the scales of attention to create a new habit of preferring and prioritizing the positive over the negative. It is perfectly suited to digital and mobile technology because it’s brief, cheap & easily accessible, and doesn’t require a shrink.

I’ve created an app called Personal Zen that embeds these techniques into an engaging, on-the-go format. Here is how it works – We see both an angry and pleasant sprite quickly pop up in a field of grass. The sprites then burrow down into the field, but only the pleasant sprite leaves a trail of grass. Our task is to trace that windy trail. Because the angry and pleasant sprite appear at exactly the same time, our brain is forced to figure out what to pay attention to. By ALWAYS following the trail of the pleasant sprite, our brains learn to automatically focus on the positive and disengage from the negative. We start building a new habit of attention. Follow the joy.

It’s deceptively simplistic, but clinical trials show that using Personal Zen and the attention bias modification techniques it is based on effectively rewires our brains to disengage from the negative and focus more on the positive – and this translates into reducing stress and anxiety after as little as single use of the app.

The Politics of Technology and Fear

So Personal Zen is a technology-based way to help heal the anxious brain. Yet, I simultaneously believe that the digital technology culture as it stands now is also one of the most surefire ways to amp UP the threat bias and make our anxious brains worse.

We mediate our lives through mobile and digital technology – we know this, it’s how we filter the tremendous complexity of our lives. But we are living in an attention economy in which news organizations, businesses, and our social networks are constantly pinging, ringing, and texting us, competing for our rapidly dwindling bandwidth of attention. We are on a digital mental treadmill. Corporations spend millions figuring out how to best keep us on that treadmill by high jacking and seducing our emotional brains, how to reward us, titillate us, and scare us into looking, clicking, buying, eyeballs on the screen, and how to mine, use, and sell our personal data.

The politics of fear are finding fertile soil in this attention economy, with fear-mongering politicians using these same techniques to drive opinion and votes, to amp up our anxieties and fears. The only good voter is an anxious voter.

The digital mental health field as it stands is not much better. There are thousands of mental health apps on the market, but fewer than 1% have ANY scientific evidence base. So, it’s essentially the Wild West, full of snake oil salesmen. This is tough on us consumers. How do we find the signal in the noise? The FTC’s crackdown on digital brain training companies like Lumosity, which was fined millions for unfounded medical claims, is a sign of the times.

The Future is Now

But let’s turn to the future.

It is crucial that at this key moment in time, we envision a new and revolutionary future for the role of technology in health. That future has to be now, and we have no time to waste. The digital technology culture in which health care is evolving is consciously and relentlessly designed to brain hack, co-opting our anxious brains, our addicted brains, our bored and restless brains. We have to disrupt the digital disruption of our lives.

Don’t get me wrong, the human race has been brain hacking for millennia, shaping and mediating how we view and make sense of reality – through language, religion, the arts, politics, education…. Along come radical advances in digital computing and now we have another tool – but it is a tool that should NOT be privileged above others. And we must take a cold, hard look at how in some contexts, the costs of these digital tools outweigh the benefits, leading to information overload, greater anxiety, and social disconnection.

So I say, let’s step off the digital mental treadmill. We all know ways to do this, ways as simple as silencing the endless rings and buzzes of our notifications, turning off our devices during meals with our family and friends, and minimizing the time as family, parents, and friends, our loved ones see the back of our devices rather than our faces. When we take these steps, we treat our attention as sacred and precious, as a resource to be spent wisely. These values must be front and center when we design and use health technology.

I challenge all of us today to reclaim technology to heal the anxious brain and heal the culture of fear: Designers, help us streamline screen time – less time with eyeballs on the screen – and design technology that facilitate our ability to live truly connected and fulfilling lives; Consumers, demand digital health tools with scientific backing and be conscious of how you’re spending your precious, precious attention; Politicians, draw on the best rather than the worst aspects of the attention economy. The only good voter is an informed voter. If we do these things, together, we will create the tools we need.

I want to break up with you. After all, you’re a cheat and a liar. But I’m not going to let you off that easily. Why? Call me foolish, call me naïve. But I have to believe that there is good in you yet and I’m going to stick with you, through better or worse.

And now, it’s definitely worse. It’s been a couple of months since the truth came out – that you “deceived consumers with unfounded claims that Lumosity games can help users perform better at work and in school, and reduce or delay cognitive impairment associated with age and other serious health conditions.” Ouch. This from no less than the Federal Trade Commission. They saw through your deception and fined you millions for it. I wish I could say I saw this coming, but my feelings blinded me.

And I did come to you with many strong and deeply-felt emotions but you decided to prey upon my fears – of not performing at my peak, of growing old, of my brain not working as quickly or well as it used to, even of developing serious health issues like Alzheimer’s disease. I was at a vulnerable point and was desperate to believe in you and your overblown claims. Looking back, it’s hard to imagine that I fell for it, actually thought that you could help me turn back the clock. But it felt so good to play your little games, to believe that I could change for the better. You seduced me.

The Standard Center for Longevity saw the warning signs back in 2014 – they issued a Consensus Statement on the brain training industry from the scientific community, stating that the industry lacks any compelling scientific evidence that their products will reverse cognitive slowing and forgetfulness, improve everyday functioning, or help to prevent dementia. But I ignored the red flags, believing that, for me at least, you would be different.

Can anyone ever really change? I have to believe it’s possible because, despite the betrayal, I believe you could be so much more than you are, Lumosity. And I think there are concrete steps you could take on the road to redemption.

First, get some real scientific validation. It’s possible you don’t know this, although it seems like you have a bazillion scientists working for you, but saying something is science-based SHOULD MEAN that you and other independent scientists have conducted rigorous scientific studies on your own brain training games and show with A HIGH DEGREE OF CERTAINTY that your actual products generalize to real life – that means, remembering where I left my car keys, performing better at work or school (not just on your computer games), or showing actual biological signs that the ol’ brain is working better. With all your money and all your testimonials (solicited through contests that promised prizes), you don’t have a bit of data that the FTC considered compelling. You need to turn this around.

Second, consider an open relationship. Lumosity, let’s see other people. You’re not meant to be in a monogamous relationship. Even with scientific evidence, why would you ever think you could make a person smarter, happier, and healthier, all on your own? You do best when you’re a really good friend – dare I say a fling? – to a person already in a committed relationship. Take for example my relationship with exercise. The single best “treatment” for physical and mental deterioration is physical activity. I’d like to focus on this relationship, and others probably should, too. Why don’t you just offer to help out on the side, give us something fun and engaging to do in our down time. You’re supposed to be a tool – and I don’t mean that kind of tool. I mean a tool that we can use when we need it, to complement the other tools we use to live well.

Third, stick to what you’re good at. You’re good at creating brief and engaging games, but you’re also really good at generating interesting data and connecting people since you’re digital. Focus more on mining that data to create more effective products, and better yet, foster the creation of communities that help people make all-around healthier choices. Instead you’ve been focusing on creating co-dependent relationships. Someone has to break it to you, so it might as well be me – screen time can only take you so far. You and other kinds of health technology need to rethink your approach. Stop taking our time, distracting us and instead get out of the way and help people spend their time well and in healthy ways. My friend Time Well Spent has been talking to me about that, and has really helped me think through my relationship with you.

So, Lumosity, I’m giving you a second chance. I know people often say – it’s not you, it’s me. Well, this time, it’s definitely you. I hope you will rise to the challenge.

Mental illness is THE public health crisis of our time, greater in terms of personal and economic costs than any other disease, dwarfing cancer, diabetes, and cardiovascular illness. Half of us Americans are at risk and likely to suffer from one of these problems in our lifetime. The global economic burden of mental illness over the next decade has been estimated at $16 trillion. Yet, this is only the tip of the iceberg because half of us never seek treatment – 45% say price is a barrier and 40% say the stigma of mental illness is a barrier.

Digital health technology is the perfect disruptive innovation for this sorry state of affairs – it directly addresses these barriers by being instantly accessible, affordable, and private. Perhaps as importantly, with mental wellness in the palm of your hand, the dialogue around mental health could be reinvented. Instead of focusing only on illness and pathology, we could focus on the pursuit of mental fitness, making it as socially acceptable as improving physical fitness.

I don’t think this is just a nice dream. We are standing on the edge of a revolution and digital technology will be at the epicenter of that revolution. But we are uncertain how to move forward. Elsewhere, I have described this state as the Wild West, a lawless frontier, full of potential.

In order to realize this potential, we need goals, guidelines, and values. We also need to create a truly cross-disciplinary dialogue to fully understand the personal and societal implications of digital mental health, and how to work with the vast amounts of data this movement will create. Until we do so, digital mental health will be a revolution without a manifesto.

A manifesto should dissolve the past, reinvent the future, define and antagonize, inspire and provoke to action, spark community and presence. Here I outline what I believe should be six core principles of the manifesto, to guide the digital mental health revolution. Vive la revolution!

Focus on Translation. For digital mental health to succeed there must be translation between the analog and the digital, between technical innovation and scientific evaluation. For example, there are thousands of mental health apps on the market, but only a tiny percentage – fewer than 1% – have ANY evidence base. Science is the best way we have to figure out which digital health tools work. It’s how we find the signal in the noise. Yet, this translation requires that people on both sides of this equation think outside their boxes. Technologists need to think randomized controlled trials and researchers need to think nimble science. Creating more academic-corporate partnerships with vision and gusto will increase innovation, reach, resources, and reality base on both sides.

Personalization.We know that one size does not fit all – in mental health as in most things. We have long talked of personalizing mental health treatments in Psychology. Without a perfect understanding of how and for whom mental health treatments work, we are far from this goal. Yet, while we shouldn’t create an unrealistic standard of everything being personalized, the massive amounts of data created by our digital signatures could move us closer towards data-driven personalization of mental health interventions. Utilizing these data in effective but responsible ways must be a core goal of the digital mental health revolution. Personalization could also provide a new platform for overcoming racial, gender, and cultural insensitivity in our treatment approaches –personalization must be based on who we are as people.

Control in the hands of individuals. We expect to self-curate our lives – our self-image, our social network, our information, our entertainment, the tools we use to navigate the world. Why should mental health be any different? We must create a play-list or Netflix model for self-curating mental wellness tools. At the same time, we need guidelines and standards, a balance between the prescriptive from professionals and personal choice. This major challenge is the gorilla in the room. How do we insure privacy while maintaining treatment integrity? How do we avoid using the carrots and sticks of “behavioral design” and gamification in controlling ways that treat individuals like rats in a maze?

Disruptive innovation. The digital mental health tools that populate the field must be truly disruptive, drastically increasing the accessibility and adoption of mental health diagnosis tools and interventions. To do this, we must first work out machine learning technologies combined with electronic medical records to improve diagnosis, treatment recommendations, and treatment delivery. Second, mental wellness tools must be in the palm of every hand. To do this, we should leverage targeted treatments that are brief and low-cost, and identify portable “active ingredients” that can be translated into many digital and cultural contexts. Therapy is not always appealing, so we must build products that are “sticky,” sophisticated, and aesthetically inspiring.

Attack stigma. Mental illness is among the most pervasive and potent of social stigmas. Mental illness is not contagious, but we fear it as if it were. The mentally ill are NOT more likely to be violent, and yet this is assumed. As long as mental illness remains a sign of disgrace and shame, people will avoid seeking help because it makes them feel broken – perhaps beyond repair. Digital mental health can’t fix all this, but it will shift the dialogue towards mental wellness rather than pathology, on building mental fitness rather than being broken. It will harness our desire for self-disclosure and “being seen” on social media to better overcome the silence that drives shame.

Understand the costs and benefits of technology. Lest this blog post come across as an ode to technology, let me stop you right there. Technology is by definition the application of scientific knowledge for practical purposes. If the technology that could transform mental healthcare was hydraulics, or kundalini yoga (and I’m not counting these out) I’d be all for it. At this moment in time, however, digital technology seems most likely to drive real innovation. But we don’t yet grasp the costs and benefits of these technologies. What does our “brain on technology” look like? What is the opportunity cost of being obsessed with and absorbed in our mobile devices? What is the impact of digital burden, of never making time for mind-wandering? We don’t know, and so we must walk a careful line between technophobia and technophilia, avoiding both.

When I talk to people about the digital health space – specifically digital mental health – I often say, “It’s the Wild West!” and everyone nods. But then I stopped to think about what I really mean by the Wild West. I realize that the metaphor holds up very well.

There is a gold rush. The California Gold Rush began on January 24, 1848. News of the gold brought some 300,000 people to California from around the world. They were called forty-niners in reference to the year the fever really hit, 1949. Tens of billions of today’s dollars in gold was recovered. The gold rush transformed the economy of California and economies all over the world.

The financial opportunity – and temptation – represented by the digital mental health revolution is similarly profound. Americans alone spend over $148 billion annually on mental and emotional health. Moreover, more than half of people suffering from emotional and mental distress will never seek treatment – meaning there is a huge, unmet need. Of these who don’t seek treatment, over 45% cite price as a barrier, and over 40% cite stigma as a barrier. Digital health tools, like mental health apps, address these barriers by being highly accessible and highly affordable. They also have the potential to neutralize stigma because, as I’ve argued before, mobile devices are the hub of our lives and thus what we do on them automatically gains an aura of “good.” Digital health therefore represents a perfect marriage between social good and economic potential, and there are plenty of forty-niners who see this opportunity and want to cash in.

There are snake oil salesmen. Indeed, many companies are jumping on the wagon and digging for digital health gold (to keep the Wild West metaphor going). Some of these companies offer great, beneficial products, but others are “snake oil salesman.” Snake oil is an old-fashioned term that tends to refer to fraudulent health products or unproven medicine, but in general refers to any product of questionable quality. A snake oil salesman is someone who knowingly sells these fraudulent products. You see these guys as comic relief in Western movies all the time, usually a traveling “doctor” selling fake medicines, who leaves town before customers realize they have been cheated.

One way for us to get around the risk of snake oil is to elevate the dialog around digital health and develop ways of evaluating the scientific quality of what’s out there, since none of this is regulated (yet). This will help us look past the shiny bottles of alluring medicines that are actually snake oil, and find the real healing agents. Psyberguide is one organization I came across that appears to be trying to do just that. If we don’t push ourselves as an industry to meet standards, we risk becoming comic relief rather than a true paradigm shift. We also risk repeating the failures of the analog healthcare system, just making them digital.

There are pioneers. I believe that a science-backed digital health revolution will be the single most important paradigm shift in the failing mental health industry. This revolution will allow people to promote their personal wellness like they do their physical wellness and fitness. It will allow people to access treatments that are effective without being too expensive, burdensome, or stigmatizing. We need to think outside of the box for a true paradigm shift to occur in how people access support for their emotional and mental health – whether that’s the transformation of how patients access their health information through electronic medical records, how health information is collated to lead to better diagnosis and treatment, how health information is gathered through tests done on mobile devices, or how interventions are accessed, through mobile health apps and digital brain training. Pioneers in digital health are rethinking how to empower the individual to promote their own mental and emotional wellness, to use personal health information to actually improve our lives, not just be monetized by big companies mining our big data.

I firmly believe that destigmatizing mental illness and emotional distress will be the linchpin in this paradigm shift. Mental health – when we say those words, we think illness, not health. We think of people being crazy, despondent. Why is that? It is because Psychology and Psychiatry have failed to make mental health a positive goal like physical health and fitness. When we struggle emotionally, we feel broken. Treatments are burdensome, hard to access, and stigmatizing. We need to be on the vanguard of a paradigm shiftaway from stigmatizing, expensive treatments emerging from the “if we build it they will come” mentality, and towards a new vision in which people are empowered to personalize their mental wellness through tools that work for them, when and where they want them.

If pioneers brave the Wild West that is the digital health field of 2015, we have a chance of creating something that transcends our humble beginnings to actually make a difference.

After decades of research on mental health treatments for conditions ranging from schizophrenia to depression, from anxiety to autism, our track record remains poor. For example, anxiety disorders alone will affect over 90 million people in the lifetime – in the U.S. alone. That’s approaching a third of our population. Yet, only a small fraction of us receive effective, long-lasting treatment. Thus, while we mental health professionals do much good and have some excellent, evidence-based treatments, we also know that, on balance, we are far from doing enough. We are failing.

I believe that there are many reasons for this failure. Psychological disorders are incredibly complex, with diverse and wide-ranging causes and manifestations that vary extremely from person to person. So we have an unbelievably tough problem to solve. But in addition, I believe that there is a two-part “recipe for disaster” that has put up additional barriers to the development of effective treatments:

The stigma of mental illness

Professionals minimize the importance of making treatments acceptable to the individual

The Stigma of Mental Illness

If you type “stigma definition” into Google, here is what comes up:

noun: stigma; plural noun: stigmata; plural noun: stigmas

a mark of disgrace associated with a particular circumstance, quality, or person.

It is no coincidence that mental illness is the paradigmatic example given by the dictionary. It is one of the most pervasive and persistent of the social stigmas. If we think about other sources of stigma – like the stigma suffered by those diagnosed with HIV/AIDS in the 80’s and 90’s and beyond – the stigma of mental illness is especially striking because mental illness is not contagious. But we fear it as if it were. The mentally ill are NOT more likely to commit violence, and yet, this is what many people fear. Take the media frenzy following the Sandy Hook Elementary School tragedy as an example of this type of assumption.

As long as mental illness remains a sign of disgrace and dishonor, people will avoid seeking professional help because it makes them feel broken – perhaps beyond repair.

Professionals Minimize the Importance of Making Treatments Acceptable to the Individual

There is another issue exacerbating the barrier represented by the stigma of mental illness. This barrier is that we scientists and practitioners, in our education, are socialized away from figuring out how to provide individuals with services they need in a way that they want – something that is obvious to any product- or service-oriented industry. Instead, we are taught to believe that we know best because we use the tools of science to develop the most efficacious treatments. The implicit narrative is: “We are the experts! We have figured out the best “medicine” for you, now take it!” This arrogance often keeps us from seeing that if we develop treatments that are too onerous or if treatments are embedded in a culture of disgrace and stigma, then we have failed to solve the problem. We have failed to meet “consumer needs.”

This is of course an overstatement and many mental health professionals actively fight against these attitudes. But there is a grain of truth here. Anyone on either side of the mental health fence – both professionals and patients – is familiar with this feeling, whether it’s acknowledged or swept under the rug.

How Digital Mental Health Tools Can Disrupt Stigma and Increase Acceptability of Treatments

In addition to breaking down barriers to effective, affordable, and accessible mental health treatment, I believe that digital – in particular mobile – mental health tools can be harnessed to have profound and lasting disruptive effects on the stigma of mental illness and on our failure to make acceptability of treatments a top priority. Here are five ways I believe digital mental health tools might just save Psychology:

If treatments are administered on a device, they are normalized

If we are successful in attempts to embed evidence-based treatments into mobile and gamified formats, I believe we can profoundly reduce the experience of and appearance of stigma. Devices have become our filters of information, our gateways to the world, sources of fun, and our hubs of connection. The actions we perform on our devices, by association, feel more “normal,” more connected to every aspect of our lives and to others. This creates a process of validation rather than shaming. By putting mental health treatments on devices, we might just be normalizing these treatments and creating positive emotional contagion – treatments become “good” by association with the devices we love. And if we gamify interventions, these effects could be strengthened even further.

Self-curating our mental health

With digital mental health tools, accessibility is exponentially increased. For example, with mobile mental health apps, you have affordable help “in the palm of your hand.” This ability to curate creates a sense of empowerment. This is “self-help” in a very real sense. With this high level of accessibility and empowerment, many of us will avail ourselves of interventions to reduce negative experiences and states. In addition, with the proliferation of digital tools to PROMOTE positive outcomes and to reach our fullest potential, we may find on the societal level that this positive focus is just as helpful – if not more so – as the focus on preventing negative outcomes. This attitude of promoting the positive is an excellent antidote to stigma. Who couldn’t benefit from promoting more of what is positive about oneself and how one lives life?

Digital health technology provides powerful platforms for community building

This is readily apparent. With greater community building comes a sense of belonging and a reduction of isolation. But digital community building also provides opportunities for effective advocacy. Of course, many such groups exist, but excellent digital mental health tools with a social media component could accelerate the creation of such systems, leveraging all the power of an individual’s full social network.

The profit motive will fuel innovation and valuing of consumer perspectives

Once interventions enter the digital and mobile technology world, the accompanying consumer focus (read $$$) will force the development of consumer-oriented products. Users have power in this domain. So, if interventions are onerous, boring, or non-intuitive, people will simply not use them. User stats will do the rest – no one will put resources into a product that people won’t use. Better ones WILL be developed.

Digital mental health increases opportunities for gamification

The gamification of mental health is beginning. At this point, we are taking baby steps, since we have an absence of a strong empirical base; in other words, there is precious little research showing that computerized games have a direct, positive influence on mental illness or on the promotion of mental wellness. But we are only in the earliest, exciting stages of this revolution. As I’ve written elsewhere, I don’t think all treatments should be computerized or gamified, nor do I think face-to-face therapy is obsolete – far from it. But I believe that if fun can be combined with powerful treatment technologies, then we can in a single step make profound progress in erasing the stigma of mental illness and creating treatments that people will truly want to use.